Provider First Line Business Practice Location Address:
1046 S PLYMOUTH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90019-6823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-671-8142
Provider Business Practice Location Address Fax Number:
877-286-3844
Provider Enumeration Date:
09/22/2011